Early detection of dementia: RCPsych result

Following on from my previous post which outlined my opposing argument, I can now share the result of this RCPsych debate:

The narrowness of the result is undeniable. Yet the motion was defeated.

It seems that my fellow professionals were not fully swayed by the determination of a “Key Opinion Leader” such as Professor Clive Ballard.

The forum of this debate is though worth reiterating: Royal College of Psychiatry, members, for Continuing Professional Development (CPD) Conference.

I might speculate that this result is indicative of a growing concern regarding the difficult to establish boundaries between ageing and disease.

What follows are the slides that I gave in riposte to Prof Ballard’s initial argument. An argument in which he advocated the pre-diagnosis of dementia.

At this point it may be worth noting that this CPD-accredited Conference (unknown to me until arrival at the conference) was sponsored by Eli Lilly UK and the Medical Protection Society.

I did not have lunch at the conference but it still could not escape my notice promotions made by bill-board and representative of Eli Lilly. This was to promote AMYVID“Cognitive Impairment: Do you have the evidence you need to reach a diagnosis?”

This promotion is rather extraordinary in that after boldly outlining encouraging statistics LILLY states that “Beta-amyloid disposition is BELIEVED to be a biomarker for Alzheimer’s disease”.

Returning to my riposte to Prof Clive Ballard. These were the slides on which I based my reply:

I started with one of my published letters in the British Medical Journal:

Confusion abounds. The recent BMJ discussion about the screening for dementia has highlighted that it is both incorrect and potentially stigmatising to consider such confusion as the preserve of our older generation.

At least six areas of confusion do seem prevalent when it comes to our understanding and collective approach to memory loss in old age:

(1) General confusion:
The general population is increasingly using the word “Alzheimer’s” instead of “dementia.” This is hardly surprising when you consider:

(2) Professional confusion:
NICE and SIGN Guidelines for Dementia both contain definitions of dementia and of Alzheimer’s disease, yet in the body of the guidelines, the terms are frequently used interchangeably.

(3) Confused ‘education’:
Much post-graduate medical “education” is sponsored by the Pharmaceutical Industry. Much awareness raising by charities is also backed by the Pharmaceutical Industry. Many political imperatives are influenced by lobbyists for the Pharmaceutical Industry. We are certainly confused about where the line lies between these activities and “marketing”?

(4) Confusion between research and clinical agendas:
Advances in research are too often extrapolated prematurely into a general clinical setting by well intentioned clinicians who may also be responding to the clamour of the latest press-release.

(5) Confused about risk:
The communication of risk is fundamental to medical practice but is undoubtedly difficult. Every intervention has the potential for benefit and for harm. We are so keen to see the former that we sometimes forget to look for the latter.

(6) Confusion about science:
Scientific evidence must be taken in context. Many universities are responding to this by making the Medical Humanities an integral part of their under-graduate medical curriculum.

The dictionary definition of confusion is: “a feeling that you do not understand something or cannot decide what to do.” We must resist the temptation to respond to confusion with over-simplification and instead find a way to acknowledge complexity.

SLIDE 1:
This is a screenshot of the latest Alzheimer’s Society film on research. The Alzheimer’s Society state that “current treatments only help with the symptoms for a short while”

SLIDE 3:In June 2010, an outcome of a judicial review for NICE guidance on drugs for Alzheimer’s disease was published.

The Judge found that NICE “was not irrational in concluding that there is no cumulative benefit to patients after 6 months treatment with these drugs”

SLIDE 4:
At last year’s national Conference, in a talk sponsored by Lundbeck, Professor Ballard presented a talk entitled “Clearing the fog: what are the barriers to evidence based prescribing in Alzheimer’s disease”

SLIDE 5:
This talk would appear to have been based on this publication of the same year in the British Journal of Mental Health Nursing.

It is worth noting that Prof Ballard, like most research academics, refers to Alzheimer’s disease and not Dementia of an Alzheimer’s type.

SLIDE 6:
In this paper Prof Ballard states “However, despite evidence of significant benefits of pharmacological treatment only 10% of dementia patients receive Acetylcholinesterase inhibitors or Memantine – this figure remaining much the same since 2008. In addition to the beneficial clinical outcomes of these treatments in the slowing of cognitive and functional decline, health economic analyses also indicate that they are cost effective”

SLIDE 7:
This article written by the CEO of Alzheimer’s Society in The Journal of Dementia Care has Jeremy Hughes stating the opposite to what his own organisation have said in recent media “Although drug treatments aren’t effective for all people with Alzheimer’s disease, they can slow down the progression of the condition for many”

SLIDE 9:
This report in the PULSE journal from January 2014 concluded that ”the analysis of data from 2012 found prescribing rates of Donepezil, Galantamine, Rivastigmine and Memantine were 50% higher than expected when compared with prevalence rates of Alzheimer’s disease.”

SLIDE 10:
In a “Think tank” Report sponsored by LILLY it was concluded in 2012 that “doctors should be rewarded for the early diagnosis of dementia” and they also “suggested targeted screening”

SLIDE 11:
Just recently, the Editor of the BMJ called Pre-dementia (in other words early diagnosis) as “another government policy, which based on this paper, might be summarised as daft and damaging”

SLIDE 12:
Dr Clare Gerada, former Chair of the Royal College of general Practitioners has openly stated, and copied to Professor Alastair Burns, our Dementia Tsar, that “screening for minor memory loss risks medicalising normal ageing”

SLIDE 14:
I remember this BBC News Report from January 2012. It featured my fellow debater who now advocates for the early detection of dementia. In this report, Prof Ballard described how brain function can start declining as early as age 45.

SLIDE 15:
The doctor and entrepreneur, Prof Claude Wischik, of Tau Therapeutics has expanded this finding in the following way: “one in five adults over 40 are impaired by Alzheimer’s”

SLIDE 16:
There are many types of dementia such that there is a risk that “Alzheimer’s” has become synonymously misunderstood as dementia. One of the first questions I am generally asked at the clinic “what is the difference between Alzheimer’s and dementia”

This is a quote I have used many times in my publications and films on early diagnosis. It is from the Lancet in 2011 in an article by my colleague Prof Ballard: